Voices from the grave should be heard
Every Monday, for a year, Dr. Juveria Zaheer ensconced herself at the Office of the Chief Coroner of Ontario and read suicide notes.
The final sad thoughts of those who had taken their lives between 2003 and 2009.
“I started five years ago,” Zaheer told the Star. “I was pregnant with my first daughter. I’d go upstairs, sit there, go through these notes, transfer them to my laptop. It was a tough process, for sure.”
The coroner’s office is quite proprietary about the archived material — 1,564 documented suicides in the province over those six years — and wouldn’t allow files to leave the premises.
But Zaheer, a clinical scientist at the Centre for Addiction and Mental Health as well as an emergency room psychiatrist, was on a mission of discovery.
“With my clinical work, I often see people on their very worst days. There’s always that hope that you’ve made their hardest days a little easier through empathy and through connecting them with the services that they deserve, to get them started on the right track. With the suicide notes, we were looking at people whose lives have ended, who have fallen through the cracks. As a psychiatrist, it’s heartbreaking.”
With her research team, Zaheer codified the data. A total of 516 files made mention of a suicide note; 290 contained notes, copies or transcriptions. Some were excluded because of illegibility or they were written in a language other than English. But they ultimately had 252 notes to work with and codify.
Interestingly, the files showed that only a minority of “decedents” left notes behind, as far as the coroner’s office could determine, although it’s possible that in a social media world the last thoughts imparted may have been sent by email or text and never retrieved.
“Our sample is pretty consistent with other samples in other countries,” Zaheer explained. “We sometimes have this romantic idea of what we’d do if it was your last thought before death. But there are so many differences and for some people suicide is a compulsive act.’’
Accompanied by alcohol or drugs, the individual might not have been fit to scribble (some actually typed) their parting meditations.
The point of this exercise, just published in the Canadian Journal of Psychiatry, was to gain insight into the subjective experiences of mental illness and mental health care as described in the notes, with a view to helping clinicians in how they manage patients with suicidal ideation, how to identify it and talk about it.
“The reason we did the study is that we felt it provided a unique opportunity to understand the experiences of people who have been suffering, who have maybe been through the system (of mental health care), so we can improve that care. We know a lot about suicide but we very rarely get a window into the minds of people in the moment before they die.”
The outcome, a study entitled “I Can’t Crack the Code” — a composite quote that speaks to the frustrations and exhaustion and often self-condemnation of those who’ve come to the end of their rope — uncov- ered themes of trying and failing to assert control over their lives, feelings of powerlessness, believing themselves a burden to loved ones when severe depression doesn’t lift, and tracking, through the brief accounts (most around 600 words) the “pathways to suicide.”
Pathways that should and can be diverted with proper strategies for coping.
“The vast majority of people are actually able to recover,” said Zainab Furqan, co-author of the report and a physician doing her residency in psychiatry. “They don’t die by suicide even if they go through periods of experiencing suicidal ideation. Through support and health (intervention), they are able to get through those really dark periods in their lives.”
These are people speaking from the grave and it’s crucial that they be heard.
“There was a subset of writers who described having very little control over their lives because they had a mental illness,” said Furqan. “They felt completely helpless to change the situation around them. Another group felt they still had a lot of control, they had a lot of opportunity to change the course of their lives. But the flip side of that was they blamed themselves for not being able to do it. Because they had control, they were to blame.”
It was distressing, admits Zaheer, sifting through notes where the depressed individual thought the world would be a better place without them, that their families would be relieved of a burden.
“I read these notes and I can say, well, that’s not true. I’ve never met a family member who has ever said, ‘I’m better off without this person.’ They identify this as the worst trage- dy of their lives.
“I’ve met people with depression where it seems the world is closing in on them, that there’s no hope in the moment or in the future, and I’ve seen these people recover. So, reading the notes is really sobering. It tells us that suicide is a major public health problem in this country, that every suicide is a tragedy and that it’s a preventable one.”
According to Statistics Canada, suicide is one the leading causes of premature death in Canada, with 4,405 suicide deaths occurring in 2015 alone. Contributing factors are, of course, diverse.
But 90 per cent of suicides suffered from demonstrable mental disorders and 30 per cent (according to existing research) had seen a professional about their mental health in the 30 days before they died.
That doesn’t speak very well to practitioners and the often user-unfriendly system of obtaining help.
One practical application of the study’s findings, says Zaheer, is assisting clinicians in understanding the common thinking patterns of people at risk. “If you see someone who describes feeling exhausted or powerless, you’ll know that they’re at higher risk and require more support in mental health care. The second major application is to encourage clinicians to dialogue with their patients: How are you sleeping? How are you eating? In addition, we need to focus on the bigger picture — understanding a patient’s view of themselves versus mental illness. Do they feel like they’re battling themselves? We need to identify distorted thinking: I’m worthless, nobody cares about me, the world is a terrible place. Because there are very effective interventions for that kind of thinking in cognitive behavioural therapy, for example.”
Peer support, for instance, — talking with those who’ve been there and come out the other side — has been undervalued and underutilized. And of course there are many broader societal factors such as affordable housing, employment, education, lives which are lonely and isolated. In recent weeks, we’ve seen extensive coverage of celebrity suicides such as Anthony Bourdain hanging himself while on a TV taping trip to Europe. As a general rule, media do not report on suicides — on the TTC, say — for fear of creating a “contagion effect.”
It’s a tricky issue when professionals are simultaneously trying to remove the stigma from discussing suicide.
“If suicide is always on a person’s mind, that can really push them into doing it,” warned Zaheer, pointing to the suicide of comedian Robin Williams and the well-intentioned commentary that “now he’s free.”
“That kind of language is dangerous. But there is a role for talking about suicide as a public health concern and focusing on the positive. We can use these notes to see how people are thinking prior to death. Most people who think this way are able to keep themselves safe. As clinicians, we can harness this way of thinking to address it and provide support. We want them to know that, even if you’re feeling helpless and exhausted, hold on to that thread of hope because people do get better, there is a way out of this darkness.”
With suicide, there’s no going back.